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  • Dispute Resolution for Medicare Plans > EmblemHealth Medicare HMO/PPO/PDP

    Member Grievance Procedures

    An EmblemHealth Medicare enrollee may file a grievance if he or she has a problem with us or one of our network providers or pharmacies related to office or prescription fill waiting times, the behavior of a network provider or pharmacist, or the inability to reach someone by phone. Complaints regarding coverage for a service or prescription drug are not considered a grievance under these terms.

    An EmblemHealth Medicare enrollee or his or her representative may file a grievance by phone or in writing no later than 60 days after the incident that precipitated the grievance. Grievances submitted in writing will be responded to in writing. Grievances submitted by phone may be responded to either by phone or in writing unless the enrollee requests a written response. All grievances related to quality of care, regardless of how the grievance is filed, will be responded to in writing.

    EmblemHealth will notify the enrollee of its decision as soon as possible, but no later than 30 days after the date EmblemHealth receives the grievance. This time period may be extended by up to 14 days if the enrollee requests such an extension or EmblemHealth can justify the need. If EmblemHealth extends the timeframe, the enrollee will be immediately notified.

    Grievances can be filed as follows:

    EmblemHealth Medicare HMO

    • In writing:  EmblemHealth Grievance and Appeal Department
                      PO Box 2807
                      New York, NY 10116
    • By phone:  1-877-344-7364

    EmblemHealth Medicare PPO

    • In writing:  EmblemHealth Grievance and Appeal Department
                      PO Box 2807
                      New York, NY 10116
    • By phone:  1-866-557-7300

      EmblemHealth Medicare PDP (non-City of New York)

      • In writing:  EmblemHealth Grievance and Appeal Department
                        PO Box 2807
                        New York, NY 10116
      • By phone:  1-877-444-7241

        EmblemHealth Medicare PDP (City of New York employees)

        • In writing:  Express Scripts
                          Attn:  Pharmacy Appeals GH3
                          6625 West 78th Street
                          Mail Route B20390
                          Bloomington, MN 55439  
        • By phone:  1-800-585-5786

          EmblemHealth members who use a TTY/TDD can dial 711 for Telecommunications Relay Services.

          Standard Reconsiderations (Appeals) - Part C

          An enrollee who has received an adverse organization determination may request that it be reconsidered.

          For standard reconsiderations, an enrollee or his or her representative must make a request within 60 calendar days of the notice of the coverage determination. This may be extended if the enrollee shows good cause (in writing). For expedited reconsiderations, an enrollee or his or her prescribing physician may make a request by phone or in writing. EmblemHealth will promptly decide whether to expedite the request.

          EmblemHealth will notify the enrollee of its decision no later than 60 calendar days from the date the request was received. If a standard reconsideration request is granted in whole or in part, EmblemHealth will effectuate the decision no later than 60 calendar days from the date the reconsideration request was received.

          Standard reconsiderations (appeals) for Medicare Part C can be filed as follows:

          EmblemHealth Medicare HMO

          • In writing:  EmblemHealth Grievance and Appeal Department
                            PO Box 2807
                            New York, NY  10116
          • By phone:  1-877-344-7364

            EmblemHealth Medicare PPO

            • In writing:  EmblemHealth Grievance and Appeal Department
                              PO Box 2807
                              New York, NY  10116
            • By phone:  1-866-557-7300

              EmblemHealth members who use a TTY/TDD can dial 711 for Telecommunications Relay Services.

              Reopening Medicare Part C

              EmblemHealth, as a NCQA (National Committee for Quality Assurance)-certified Medicare Managed Care Organization, does not recognize Peer-to-Peer Conversations as a mechanism to change adverse determination decisions. Therefore, the only mechanisms available for physicians to challenge an initial adverse organization determination are to either:

              1. Submit Reconsideration per Section 70.2 in the Medicare Managed Care Manual (MMCM) as described in the Appeal Rights page attached to the Medicare Denial Notice. Reopening requests must be clearly stated in writing and include the specific reason for requesting the Reopening such as good cause and new and additional material evidence or;
              2. Submit a written Reopening Request per Section 130.1 in the MMCM.

              In the event the subject of an appeal is to address a clerical error, (minor errors or omission) EmblemHealth will process the request as a Reopening, instead of a Reconsideration. A Reopening is defined as a remedial action taken to change a final determination or decision even though the determination or decision was correct based on the evidence of record. The process of Reopening applies only to Medicare Part C products and does not apply to Medicare Part D services.

              Reopening requests must be submitted within 1 year of the initial determination however the timeframe may be extended if good cause is established. EmblemHealth will not reopen an issue that is under appeal until all appeal rights, at the particular appeal level, have been exhausted. The decision to grant the Reopening request is solely EmblemHealth’s discretion.

              Good cause is established when:

              • The evidence that was considered in making the organization determination decision clearly shows on its face that an obvious error was made at the time of the organization determination decision. For example, a piece of evidence could have been contained in the file, but misinterpreted or overlooked by the person making the determination;
              • There is new and additional material evidence that was not available or known at the time of the initial organization determination decision. New and material evidence is evidence that may result in a conclusion different from that reached in the initial organization determination.

              Note: A general statement of dissatisfaction is not grounds for a Reopening. When possible, please use the Medicare Organization Determination Reopening Request Form when submitting Reopening requests.

              The Reopening Request Form, along with any additional relevant information, can be mailed or faxed to:

              EmblemHealth
              ATTN: Predetermination Department, 4th Floor
              441 9th Avenue
              New York, NY 10001

              Fax: 212-510-3006

              If the request is found not to qualify under the Reopening Process, EmblemHealth will advise the enrollee or his or her representative of any appeal rights they may have and provide the time frame to request an appeal assuming the original denial has not expired.

              For additional information, please go to the Medicare Managed Care Appeals & Grievances section of the CMS website: http://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/index.html.

              Standard Redeterminations (Appeals) - Part D

              An enrollee who has received an adverse coverage determination for a drug may request that it be redetermined.

              For standard redeterminations, an enrollee or his or her representative must make a redetermination request within 60 calendar days of the notice of the coverage determination. This may be extended if the enrollee shows good cause (in writing). For expedited redeterminations, an enrollee or their prescribing physician may make a request by phone or in writing. EmblemHealth will promptly decide whether to expedite the request.

              EmblemHealth will notify an enrollee of the decision no later than 7 calendar days from receipt of the request. If a standard redetermination request is granted in whole or in part, EmblemHealth will authorize the drug in question no later than 7 calendar days from receipt. If a standard redetermination request for payment is granted in whole or in part, EmblemHealth will effectuate the decision no later than 7 calendar days from receipt of the request and make payment no more than 30 days from receipt. 

              Standard redeterminations (appeals) for Medicare Part D can be filed as follows:

              EmblemHealth Medicare HMO

              • In writing:  EmblemHealth Grievance and Appeal Department
                                PO Box 2807
                                New York, NY  10116
              • By phone:  1-877-344-7364

                EmblemHealth Medicare PPO

                  • In writing:  EmblemHealth Grievance and Appeal Department
                                    PO Box 2807
                                    New York, NY  10116
                  • By phone:  1-866-557-7300

                    EmblemHealth Medicare PDP (non-City of New York)

                      • In writing:  EmblemHealth Grievance and Appeal Department
                                        PO Box 2807
                                        New York, NY  10116
                      • By phone:  1-877-444-7241

                        EmblemHealth Medicare PDP (City of New York employees)

                          • In writing:  EmblemHealth Grievance and Appeal Department
                                            PO Box 2807
                                            New York, NY  10116
                          • By phone:  1-877-444-7241

                            EmblemHealth members who use a TTY/TDD can dial 711 for Telecommunications Relay Services.

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                            Glossary terms found on this page:

                            An activity of EmblemHealth or its subcontractor that results in:

                            • Denial or limited authorization of a service authorization request, including the type or level of service
                            • Reduction, suspension or termination of a previously authorized service
                            • Denial, in whole or in part, of payment for a service
                            • Failure to provide services in a timely manner
                            • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

                            A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

                            Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

                            The government agency responsible for administering the Medicare and Medicaid programs.

                            Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

                            • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
                            • Treatment experienced through the plan, its providers or contractors
                            • Any concern with the plan, its benefits, employees or providers.

                            An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

                            A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

                            A complaint process whereby the member, or the member's duly authorized representative, may seek review of benefit determinations or other determinations made by EmblemHealth or a delegate relating to the member's health plan.

                            An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

                            Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

                            Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

                            A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

                            An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

                            A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called NCQA.

                            A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.

                            The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

                            A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

                            A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

                            A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

                            A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

                            A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

                            • Doctor of medicine
                            • Doctor of osteopathy
                            • Dentist
                            • Chiropractor
                            • Doctor of podiatric medicine
                            • Physical therapist
                            • Nurse midwife
                            • Certified and registered psychologist
                            • Certified and qualified social worker
                            • Optometrist
                            • Nurse anesthetist
                            • Speech-language pathologist
                            • Audiologist
                            • Clinical laboratory
                            • Screening center
                            • General hospital
                            • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

                            A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

                            A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

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